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Ageing Prisoners: an Introduction to Geriatric Health-Care Challenges In International Review of the Red Cross (2016), 98 (3), 917–939. Detention: addressing the human cost doi:10.1017/S1816383117000364 Ageing prisoners: An introduction to geriatric health-care challenges in correctional facilities Rachael Bedard, Lia Metzger and Brie Williams Dr Rachael Bedard, MD, is an Assistant Professor in the Department of Medical Education at the Icahn School of Medicine at Mount Sinai in New York City, and a Geriatrics and Palliative Care Specialist in the jails on Riker’s Island for the New York City Department of Correctional Health Services. Lia Metzger, BA, is an Assistant Clinical Research Coordinator in the University of California, San Francisco (UCSF) Division of Geriatrics. Ms Metzger supports research projects focused on health care for older adults in the criminal justice system under Dr Brie Williams of the UCSF. Dr Brie Williams, MD, MS, is a Professor of Medicine in the Division of Geriatrics, Founding Director of the Criminal Justice & Health Program at UCSF, and Director of the UCSF Criminal Justice Aging Project of Tideswell at UCSF. Dr Williams works with collaborators from the criminal justice, public safety and legal fields to apply academic medicine, geriatrics and palliative care to transform criminal justice health care through policy- driven research and education. Abstract The rise in the number of older prisoners in many nations has been described as a correctional “ageing crisis” which poses an urgent financial, medical and programmatic challenge for correctional health-care systems. In 2016, the © icrc 2017 917 R. Bedard, L. Metzger and B. Williams International Committee of the Red Cross hosted a conference entitled “Ageing and Imprisonment: Identifying the Needs of Older Prisoners” to discuss the institutional, legal and health-care needs of incarcerated older adults, and the approaches some correctional facilities have taken to meeting these needs. This article describes some of the challenges facing correctional systems tasked with providing health care to older adults, highlights some strategies to improve their medical care, and identifies areas in need of reform. It draws principally on research and examples from the United States to offer insights and recommendations that may be considered in other systems as well. Keywords: ageing, incarceration, geriatrics, palliative care, hospice, compassionate release. The ageing prison population The worldwide population is ageing dramatically.1 This phenomenon is also reflected in correctional populations throughout the world. For example, in the United Kingdom the overall prison population grew by 51% between 2000 and 2009, while the population over the age of 60 grew by 216%.2 In Japan, the number of prisoners over the age of 60 increased by 160% between 2000 and 2006.3 Such a rapid rise in the number of older prisoners has been described as a correctional “ageing crisis” which poses an urgent challenge for correctional health-care systems – especially those poorly equipped to meet the complex needs of older adults.4 While these ageing trends are seen in many criminal justice systems throughout the world, they are most profound in the United States. From 1990 to 2009, the total US prison population doubled while the number of incarcerated individuals aged 55 or older increased by 300%,5 and the median age of state prisoners increased from 30 to 36 years.6 This demographic shift has continued in the United States even as the growth of the general prison population has decreased; between 2009 and 2013, the population of US federal prisoners aged 1 Wan He, Daniel Goodkind and Paul Kowal, An Aging World: 2015, US Census Bureau, International Population Reports, P95/16-1, US Government Publishing Office, Washington, DC, 2016. 2 United Nations (UN) Office on Drugs and Crime, Handbook on Prisoners with Special Needs, New York, 2009, available at: www.unodc.org/pdf/criminal_justice/Handbook_on_Prisoners_with_Special_Needs. pdf (all internet references were accessed in May 2017). 3 Ibid. 4 Brie A. Williams, James S. Goodwin, Jacques Baillargeon, Cyrus Ahalt and Louise C. Walter, “Addressing the Aging Crisis in U.S. Criminal Justice Health Care”, Journal of the American Geriatric Society, Vol. 60, No. 6, 2012. 5 Bureau of Justice Statistics (BJS), Prisoners Series: 1990–2010, US Department of Justice (DoJ), Office of Justice Programs (OJP), Washington, DC, available at: http://bjs.ojp.usdoj.gov/index.cfm?ty=pbse&sid=40. 6 BJS, Aging of the State Prison Population, 1993–2013, DoJ, OJP, Washington, DC, May 2016, available at: www.bjs.gov/content/pub/pdf/aspp9313_Sum.pdf. 918 Ageing prisoners: An introduction to geriatric health-care challenges in correctional facilities 49 or younger decreased by 1%, whereas the number of prisoners aged 50 or older increased by 25%.7 Older prisoners now represent approximately 10% of the US state prison population.8 This article describes some of the challenges facing correctional systems tasked with providing health care to older adults, highlights some innovative approaches being taken to optimize the care of incarcerated older adults, and draws attention to some areas in need of reform. Drawing on evidence developed primarily in the United States and to a lesser extent Europe, it draws conclusions and makes observations that are widely applicable to correctional facilities worldwide. Geriatric health-care in the correctional setting While health-care professionals outside of the criminal justice system typically use the age of 65 to define which individuals are “older adults” or “geriatric”, the demarcation between “young” and “old” in correctional settings is less well defined. This is because many criminal justice-involved individuals experience multiple chronic physical and/or mental health conditions and physical disabilities at relatively young ages.9 They are also more likely to have experienced profound stress and/or trauma over their lifetime, to have a history of substance use disorder and/or homelessness, and to have had limited access to quality health-care and education.10 The high degree of early-onset medical and social complexity found in this population is often referred to as “accelerated ageing”.11 To account for accelerated ageing, many jurisdictions consider individuals in their 50s to be “older prisoners”.12 Most correctional facilities were designed to restrict the liberty of young people, not to provide optimal care for the aged. As a result, correctional facilities are often ill-equipped to meet the needs of older adults with complex medical conditions and physical disabilities. These facilities often require residents to contend with challenging environmental features such as poor lighting, steep staircases, dimly lit walkways, high bunk beds and low toilets. The rise in the number of incarcerated older adults has led some correctional facilities to introduce environmental modifications for residents with physical disabilities and 7 Office of the Inspector General, The Impact of an Aging Inmate Population on the Federal Bureau of Prisons, DoJ, Washington, DC, February 2016, available at: https://oig.justice.gov/reports/2015/e1505.pdf. 8 BJS, above note 6; BJS, Prisoners in 2015, DoJ, OJP, Washington, DC, December 2016, available at: www. bjs.gov/content/pub/pdf/p15_sum.pdf. 9 B. A. Williams et al., above note 4. 10 Ron H. Aday, Aging Prisoners: Crisis in American Corrections, Praeger, Westport, CT, 2003. 11 Ibid. 12 Brie A. Williams, Marc F. Stern, Jeff Mellow, Meredith Safer and Robert B. Greifinger, “Aging in Correctional Custody: Setting a Policy Agenda for Older Prisoner Health Care”, American Journal of Public Health, Vo1. 102, No. 8, 2012. 919 R. Bedard, L. Metzger and B. Williams system-wide enhancements to manage their complex health needs. Together these factors likely contribute to high correctional costs.13 Yet a precise accounting of the health-care costs generated by incarcerated older adults is frequently hampered by a lack of data transparency on the part of correctional systems, and by differences in how systems that do share their cost data define and report on expenses.14,15 Best-guess estimates suggest that the average incarceration-related costs for older adults in the United States are up to nine times higher than for younger adults.16 In 2013, the US Office of the Inspector General found that the Federal Bureau of Prisons spent $881 million to incarcerate individuals aged 50 or older.17 Furthermore, state prisons that house the highest proportion of older adults generate medication costs that are fourteen times higher than the prisons with the lowest proportion of adults aged 50 and older.18 Incarcerated older adults also experience unique criminal justice outcomes. Compared to their younger counterparts, older adults tend to incur fewer disciplinary actions while incarcerated and have lower recidivism rates once released. For example, in the US Federal Bureau of Prisons statistics, individuals aged 50 or older account for 19% of the population but generate only 10% of misconduct incidents.19 Over the same period, the three-year recidivism rate for all individuals leaving US federal prisons was 41%, while it was 15% for persons aged 50 or older.20 In many nations, incarcerated individuals are entitled by law to an equivalent standard of health care that is received by free individuals in their community. For example, the International Covenant on Economic, Social and Cultural Rights affirms “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”.21 The United Nations Basic Principles for the Treatment of Prisoners establishes that “[p]risoners shall have access to the health services available in the country without discrimination on 13 Tina Maschi, Deborah Viola and Fei Sun, “The High Cost of the International Aging Prisoner Crisis: Well- Being as the Common Denominator for Action”, The Gerontologist, Vol. 53, No. 4, 2013; Cyrus Ahalt, Robert L. Trestmann, Josiah D. Rich, Robert B. Greifinger and Brie A. Williams, “Paying the Price: The Pressing Need for Quality, Cost and Outcomes Data to Improve Correctional Healthcare for Older Prisoners”, Journal of the American Geriatrics Society, Vol.
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